Elbow flexion and extension occur through the ulnohumeral and radiocapitellar articulations. Along with the proximal radioulnar joint, the radiocapitellar articulation further provides an important interface to forearm rotation. Because of these important functions, the elbow plays a key role in placing the hand in space. Limited motion at the elbow can therefore lead to significant functional impairment.
Causes of elbow stiffness include trauma, burns, osteoarthritis, inflammatory arthritis, hemophilia, and infection.1 The elbow joint has a high propensity for stiffness. Theories accounting for this include the high congruity between the proximal ulna and distal humeral trochlea, the presence of three articulations within a single synovial cavity, and the proximity of the capsule to the ligaments and overlying muscles.2 Also, the elbow joint capsule plays a key role in the development of posttraumatic stiffness. The normal elbow capsule is thin and translucent, providing the required compliance for a full arc of motion.3 However, marked thickening of the capsule is observed in posttraumatic elbow contracture. At the molecular level, a decrease in type III collagen and increased proliferation of myofibroblasts have been linked to increased expression of transforming growth factor-β1, connective tissue growth factor, and α-smooth muscle actin.4-6
The goal of treatment of the stiff elbow is to provide increased range of motion (ROM) without an increase in pain or the development of instability. The main indication for elbow-release surgery is stiffness that limits activities of daily living. Except for high-level athletes, such as gymnasts, who require terminal extension to lock the elbow, extension loss is better tolerated than flexion loss. Specifically, loss of elbow flexion past 110° exceeds the ability of positional adaptation of the neck, wrist, and shoulder, thereby leading to inability to button a collar, shave the face, place an earring, or tie a scarf.7 It is commonly accepted that most activities of daily living can be performed with a 100° arc of flexion-extension, ideally with at least 130° of elbow flexion.8
With the exception of primary osteoarthritis and extensive heterotopic ossification, which do not typically respond to nonsurgical measures, formal therapy and splinting should be attempted for a period of at least 3 to 4 months before considering surgery on the contracted elbow. In this setting, surgical management is indicated only after improvement in ROM has plateaued and function remains limited. In posttraumatic elbow contracture, soft-tissue equilibrium should be reached, as demonstrated by the absence of edema or erythema. Modalities used to reduce residual swelling include ice, elevation, and active motion. The use of compression sleeves, nonsteroidal anti-inflammatory drugs, and/or a short-term oral steroid taper may also help in reducing residual edema. A standard exercise program may be started under the guidance of a therapist for mild posttraumatic elbow contractures. In patients with a functional arc of <100°, a trial of a patient-adjusted static-progressive splint is recommended (using the principles of passive progressive stretch) (Figure 1). This typically requires 30-minute splint periods several times per day.9 Use of this approach has shown that ROM may be significantly increased, thereby avoiding surgery in many posttraumatic patients.9,10
Several authors have recommended manipulation under anesthesia for the management of the stiff elbow.11-14 Duke et al11 reported improvement from an average 55° of motion arc (range, 35° to 90°) to 85° (range, 25° to 110°). Fifty-five percent of patients had an improvement in ROM. However, manipulation under anesthesia may be most indicated for recurrent elbow stiffness after surgical release. Araghi et al14 studied 51 patients who underwent manipulation under anesthesia at an average of 40 days after open surgical elbow release. The authors reported an improvement of 40° in motion arc. Reported complications with this procedure include transient ulnar neuritis11,14 and the potential for ligament disruption and fracture.15
In certain cases, such as stiffness in the setting of joint subluxation, incongruity, or ligamentous insufficiency, a two-staged approach may be required. One may first need to reduce the joint and repair or reconstruct the ligaments with a goal of initially obtaining a concentric joint with expected stiffness. Once soft-tissue equilibrium occurs, the joint can be properly released in an effort to achieve motion and function.16
In patients with closed head injuries and concomitant neurologic dysfunction, results may be unpredictable, especially in the presence of heterotopic ossification.17 Joint space narrowing alone is not an absolute contraindication to elbow release. However, release of an incongruous elbow or one with pain through the mid arc of motion should be performed with caution because it may lead to increased pain. An adequate soft-tissue envelope should be present when considering an elbow release.
Active patient participation plays a key role in achieving successful outcomes. Surgery should therefore be avoided in noncompliant patients, such as those with uncontrolled psychiatric conditions or substance abuse.
Routine preoperative assessment of patients with elbow stiffness should include a detailed history. If trauma was present, then the initial injury, duration of immobilization, and type and timing of previous surgery and therapy should be investigated. A history of concomitant closed head injury and the occurrence of burn injuries, even remote to the elbow, may further help in understanding the risk of heterotopic ossification.18
Physical examination includes a careful assessment of scars, ROM in flexion and extension, and forearm rotation. Poor quality of the overlying skin and soft-tissue envelope, as seen after burns, open injuries, or multiple surgeries, may require consultation for possible flap coverage. A standardized method of ROM measurement is paramount to allow for reliable monitoring postoperatively. Pain should be recorded during motion. If pain is elicited at terminal extension or flexion, underlying soft-tissue or bony impingement should be suspected. Pain in the mid arc of motion suggests degenerative changes or incongruity at the ulnohumeral joint.19 Pain and crepitus during forearm rotation is indicative of radiocapitellar joint disease. Finally, a detailed sensory and motor examination should be performed. Particular attention is paid to the ulnar nerve. Signs of ulnar neuritis may include sensory and motor loss or tingling and numbness in the small and ring fingers elicited with nerve percussion or during an elbow flexion test. On occasion, ulnar nerve tension and dysfunction may manifest simply as medial elbow pain that occurs with flexion.
Plain AP, lateral, and oblique lateral radiographs are evaluated to assess the joint anatomy, articular congruity, and presence and location of implants or osteophytes that may be limiting motion (Figure 2, A). CT with surface rendering is quite helpful in providing a preoperative template for bony débridement. This allows for a detailed understanding of the three-dimensional location of osteophytes and heterotopic bone (Figure 2, B and C). Furthermore, ossification of the lateral and medial ligament complexes can be identified.20
In the presence of neurologic symptoms, electromyography and nerve conduction velocity studies can be useful as confirmatory studies. However, in most instances, physical findings of sensory loss, motor weakness, or nerve hypersensitivity are sufficient to confirm the presence of nerve compression,21 especially of the ulnar nerve.
From a purely anatomic standpoint, improving elbow flexion requires removing posterior soft-tissue structures that may be tethering motion, namely the posterior joint capsule and triceps muscle adhesions. Furthermore, any mechanical blocks to flexion anteriorly must be removed, including osteophytes on the coronoid process or in the coronoid and radial fossae (Figure 3, A). To restore elbow extension, the anterior joint capsule must be released. Osteophytes at the tip of the olecranon and bony overgrowth in the olecranon fossa must also be removed (Figure 3, B). Loose bodies and any hardware that may be limiting ROM need to be addressed. Finally, heterotopic ossification that is limiting ROM will require resection.
Calcification of the collateral ligaments is common in posttraumatic cases and does not represent true heterotopic bone.18 True ligament ossification, however, may need to be addressed at the time of surgery. In most cases, only resection of the ossified posterior band of the medial collateral ligament (MCL) (ie, the posteromedial capsule) is required to maximize elbow flexion without disrupting the anterior band of the ligament. In severe cases leading to ankylosis, ossified ligaments may require formal release. If intraoperative instability is identified, typically repair or reconstruction of only the lateral collateral ligament is required.
A single-injection regional block with a long-acting anesthetic is the most common method of anesthesia. This provides the advantage of postoperative analgesia and muscle relaxation, allowing for immediate motion. An indwelling catheter may be used to provide prolonged regional anesthesia. The patient is positioned supine with the extremity on a standard operating room table.
Several approaches have been described in the literature, including anterior, posterior, lateral, and medial.1,12,21-28 The lateral and medial approaches allow access to both the anterior and posterior aspects of the elbow joint and are most commonly employed. The lateral approach has historically been preferred for simple contractures because of its simplicity and its ability to access all three elbow articulations (ulnohumeral, radiocapitellar, and proximal radioulnar). However, it does not provide access to the ulnar nerve. The medial approach, by contrast, gains direct access to the ulnar nerve for release and/or transposition, thus providing subsequent safe access to the anterior and posterior aspect of the elbow. Furthermore, the medial approach provides a more favorable cosmetic scar and a more direct release of the posteromedial ulnohumeral joint capsule, which has been proposed to be a restraint to terminal elbow flexion.29,30 The main disadvantages of the medial approach are the inability to address lateral joint pathology, the proximity of the medial antebrachial cutaneous nerve, and the potentially greater muscle morbidity when elevating the flexor-pronator origin. Occasionally, an anterior approach to the elbow is required to excise extensive anterior heterotopic ossification, especially around the radial nerve anterior to the radiocapitellar joint. In these cases, care should be taken to identify the radial nerve proximally between the brachioradialis and brachialis muscles.
The ulnar nerve deserves special mention. Patients with elbow stiffness frequently exhibit preoperative symptoms and signs of nerve dysfunction.31 In fact, in posttraumatic cases, nerve tension may, in part, be responsible for the lack of elbow flexion recovery. Elbow release with acute recovery of flexion may additionally place the ulnar nerve under undue tension, leading to postoperative neuritis or true nerve palsy. Thus, decompression of the ulnar nerve (with or without transposition) should be considered in all cases of stiff elbow surgery.
The decision whether to use a medial or lateral approach is based on surgeon preference and patient factors. In most instances, a complete elbow release can be performed through either approach, but occasionally a dual approach is required to address all relevant pathology. A single posterior skin incision has been advocated to address both the medial and lateral aspects of the elbow and to lower the incidence of cutaneous nerve injuries that can occur with more direct medial and lateral surgical approaches.12 This incision requires raising large skin flaps that may lead to subsequent seroma formation.
The medial intermuscular septum can, in most instances, be readily palpated and serves as a landmark throughout the procedure.21 An incision starting 6 to 8 cm proximal to the medial epicondyle and 1 cm posterior to the medial intermuscular septum is carried distally parallel to the septum, curving anteriorly down the proximal forearm for 5 to 6 cm. Dissection is performed through subcutaneous tissue while preserving the sensory branches of the medial antebrachial cutaneous nerve located between subdermal fat and fascia. The trunk of this nerve is located in the anterior skin flap, with branches crossing from anterior to posterior typically at and distal to the epicondyle. Full-thickness flaps are elevated until the medial epicondyle and the entire flexor-pronator muscle origin are exposed (Figure 4, A and B). The ulnar nerve is identified posterior to the septum and is released proximal to the medial epicondyle, proceeding distally through the flexor carpi ulnaris. If prior surgery on the nerve has been performed, dissection is best started proximal to the original zone of surgery.
The posterior aspect of the elbow is exposed by raising the triceps off the intermuscular septum, the humerus, and the joint capsule. (Figure 4, C). Once the posterior joint capsule is fully visualized, it is circumferentially excised from its humeral and ulnar attachments, thereby exposing the olecranon fossa. The fat pad is elevated or resected, and the olecranon fossa is débrided, removing fibrous tissue, osteophytes, and loose bodies. Preoperative CT imaging is useful in understanding the depth and degree of bone resection required (Figure 2, B). By elevating the triceps posteriorly, one should be able to clearly view the medial ulnohumeral joint. The tip of the olecranon is removed with an osteotome and the fossa deepened with a burr until no further impingement is noted. In osteoarthritis, care is taken not only to deepen the fossa but also to widen it medially and laterally. Similarly, in osteoarthritis, osteophytes that develop along the medial and lateral margins of the olecranon tip should be removed.
The posterior bundle of the MCL is a thickening of the posteromedial capsule that has been proposed to be a potential restraint to elbow flexion.29,30 Once the ulnar nerve has been released, the posteromedial capsule can be identified on the floor of the cubital tunnel. Safe capsular release can subsequently continue along the posteromedial joint line to improve flexion. The location of the anterior bundle of the MCL, spanning from the anteroinferior aspect of the medial epicondyle to the sublime tubercle, should be kept in mind to avoid injuring it anteriorly and to preserve elbow joint stability. It should be safely protected beneath the flexor-pronator muscle origin.
Exposure of the anterior aspect of the elbow is achieved by elevating the brachialis muscle proximally and the anterior two thirds of the flexor-pronator muscle origin distally. To achieve this, the brachial fascia is incised just anterior to the intermuscular septum. Dissection at this level should be kept parallel to the septum, advancing directly onto the medial cortex of the humerus. Coursing too far anteriorly may put the median nerve in jeopardy, which is typically protected by elevating the entire brachialis off bone. Distally, dissection continues into the flexor-pronator origin while care is taken to leave a small cuff of posterior fascia for later repair. At the level of the medial epicondyle, the flexor-pronator origin is split, elevating approximately the anterior two thirds of the origin parallel to its fibers (Figure 4, D). In this way, the anterior bundle of the MCL is protected.24
To safely elevate the flexor-pronator mass off the underlying anterior capsule, a pair of blunt-tipped scissors (ie, curved Mayo) is helpful. Care is taken to stay directly on top of the capsule, elevating the flexor-pronator and brachialis muscles anteriorly. Once isolated, the capsule is excised. In posttraumatic cases, the capsule can be quite thick and adherent to the anterior humerus. In osteoarthritis, it is typically thin and easily elevated from the underlying joint. The anterior aspect of the elbow can now be visualized, allowing for débridement, loose body removal, and deepening of the coronoid and radial fossae (Figure 4, E). There should be a concavity above both the central trochlea and the capitellum to accept the coronoid and the radial head, respectively. If present, osteophytes on the tip of the coronoid are then removed.
Once the release has been completed, terminal elbow flexion and extension are recovered slowly, often with repeated slow and gentle manipulation of the elbow. In cases of longstanding contracture, the brachialis and/or triceps muscles may be tight. Care is taken to release these bluntly quite proximally from the humeral shaft and to maintain the positions of maximum flexion and extension for several minutes to allow for relaxation of any myostatic contracture. Tendon lengthening is not recommended. It may be useful to rotate the forearm at maximum flexion, looking particularly for crepitus. Crepitus may suggest impingement between the radial head and the radial fossa above the capitellum.
Hemostasis is obtained, and a drain is typically placed into the posterior joint. The flexor-pronator origin is repaired, and the ulnar nerve is most commonly transposed anteriorly into a subcutaneous position after release of the distal aspect of the medial intermuscular septum (Figure 4, F). After wound closure, a soft-tissue compressive dressing is applied to the upper extremity. The anterior dressing and padding over the antecubital fossa may be removed to permit adequate elbow flexion in the dressing postoperatively.
An 8- to 12-cm skin incision is made extending from the lateral supracondylar ridge to the interval between the anconeus and extensor carpi ulnaris distally (ie, Kocher interval) (Figure 5, A). Posteriorly, the triceps is elevated off the humerus, and the posterior capsule is excised, allowing visualization of the posterior joint as well as of the lateral ulnohumeral articulation (Figure 5, C). The posterior joint is cleaned as described for the medial approach.
Distally, the lateral gutter in the posterior aspect of the radiocapitellar joint can be evaluated (ie, the “soft spot” of the elbow). This region often harbors loose bodies and proliferative synovitis. The lateral gutter can be accessed by simply reflecting the anconeus posteriorly with the triceps and incising the joint capsule proximal and posterior to the radial head (Figure 5, B). Care is taken not to remove tissue past the proximal margin of the radial head so as to protect the lateral collateral ligament complex.23 Osteophytes and bony overgrowth behind the capitellum are sometimes seen in osteoarthritis. If present, these are removed because they might otherwise limit terminal extension.
Anterior joint exposure is obtained by elevating the brachialis off the humerus proximally. Distally, dissection continues just anterior to the epicondyle and then between the extensor carpi radialis longus (ECRL) and extensor carpi radialis brevis (ECRB) muscles (Figure 5, D). This interval is most easily identified at the posterior border of the muscle belly of the ECRL, which is devoid of overlying fascia, and the ECRB, which has a discrete white fascia. Because the ECRL partially covers the ECRB anteriorly, initial dissection between these two muscles follows an oblique path from posterior to anterior as the ECRL is lifted off the ECRB. Once the anterior border of ECRB is identified, dissection continues on its deep surface onto the anterolateral capsule of the elbow. The anterior muscle sleeve, comprising the brachialis and the ECRL, is then elevated off the anterior joint capsule with a pair of blunt-tipped scissors (Figure 5, E). By not disrupting the ECRB and the remaining extensor muscle origins, the underlying lateral ligament complex is preserved and lateral elbow stability maintained.26 Once completely exposed, the anterior joint capsule is resected (Figure 5, F). As with the medial approach, the radial and coronoid fossae are cleared, and osteophytes are removed. During anterior retraction and excision of the anterior capsule, the surgeon should be mindful of the deep branch of the radial nerve, which lies just anterior to the capsule at the level of the radiocapitellar joint.
If limitation in forearm rotation is present, the radiocapitellar and the proximal radioulnar joints can be inspected at this time. Spurs off the proximal radioulnar articulation may be resected if required. Adhesions between the radial head and overlying annular ligament and capsule anteriorly can be released, as well, in posttraumatic cases. In patients with osteoarthritis, it is not uncommon to identify cartilage loss on the end-bearing surface of the radial head. Even if present, however, a radial head resection is rarely indicated in this population. Although that articulation may be the “wear generator,” leading to elbow arthritis, it is rarely symptomatic following joint débridement and release. The fascial splits are closed anatomically, and typically a drain is placed (Figure 5, G).
Several postoperative rehabilitation programs may be effective. We favor immediate continuous passive motion (CPM) postoperatively while the regional block is still present to help maintain the motion gained at surgery and to aid in the early management of edema. Formal therapy is begun on postoperative day one. The bulky dressing is removed, and a compression sleeve or elastic bandage is used to limit swelling. Active and gentle passive elbow motion is combined with intermittent continuous passive motion. To help maintain elbow extension, weighted passive stretches are helpful, using a 2-pound wrist weight (not a weight held in the hand) with the arm extended over a bolster. These are performed for 10 to 15 minutes several times daily as tolerated. Because the collateral ligaments are not released at surgery, typically no restrictions are placed on physical therapy. Prolonged in-hospital CPM with the use of an indwelling regional block catheter may be warranted in isolated cases of severe contractures.
Static progressive elbow bracing is also begun early in the postoperative period. The brace is worn for approximately 30 minutes, two or three times a day. Flexion and extension are alternated, based on the preoperative deficit and the early progress of the elbow. Indomethacin is commonly prescribed for 3 weeks postoperatively as prophylaxis against heterotopic ossification.18 Radiation therapy is not indicated for osteoarthritis with bone overgrowth. Even though the supporting evidence has been questioned,32 single-fraction radiation therapy in a dose of 700 cGy within the first 48 hours of surgery may be used in selected cases in which extensive heterotopic bone has been removed.33
Patients are typically discharged home on postoperative day one. Home physical therapy is performed daily thereafter, including active and passive exercises, continuous passive motion, weighted stretches, and patient-adjusted bracing. Progress should be monitored closely by a therapist who is familiar with the procedure and protocol. Although most elbow motion is gained during the first 6 to 8 weeks, patients not uncommonly continue to make gains in terminal flexion and extension (especially flexion) for several months postoperatively. Continuous passive motion is typically discontinued at 3 to 4 weeks, but bracing is continued for several months as required. As long as the patient is able to obtain full elbow flexion and extension once per day (eg, using the progressive brace), a favorable prognosis exists with respect to ultimate outcome if vigilance is maintained with the program.
Open elbow release provides a functional arc of elbow motion in most cases.34 Patients can expect the final ROM achieved at 1 year to be maintained for up to 10 years.35 A history of prior surgery has not been shown to affect the final outcome.2,15,17,30,31,36-38 Greater improvement in ROM and higher satisfaction can be expected in patients with more severe contractures and after resection of heterotopic ossification.31,37,39,40 Although children and adolescent patients with extra-articular elbow contracture release commonly achieve similar outcomes as adults, as a group, patients between the ages of 10 and 20 years have less predictable outcomes than do older individuals.41 Furthermore, over time, these young patients lose on average 25° of motion arc compared with values measured intraoperatively.41 The etiology of this is not entirely clear, but it may involve compliance or possibly a more vigorous healing response in children, leading to recurrent contracture. Although elbow release surgery is typically performed for motion, pain relief is often significantly improved.35 This is of special interest because pain is the strongest predictor for health status and disability scores after elbow release.42 A summary of outcomes after lateral and/or medial elbow release is presented in Table 1.
Avoiding Pitfalls and Complications
The most frequently reported complications after open elbow release are ulnar neuritis, wound complications (including wound hematoma and infection), loss of ROM, heterotopic ossification, pain, complex regional pain syndrome, triceps insufficiency, and instability12,26,28-31,35,37,38,40,43-46 (Table 1). Patient selection and education, as well as careful attention to surgical technique to restore ROM and preserve joint stability, are essential. A low threshold for ulnar transposition should exist, and patients should be followed closely for early identification of wound complications.
In the setting of failed nonsurgical treatment of the stiff elbow, surgical release can yield to sustained improvement of ROM and patient quality of life. Adequate patient selection, a clear understanding of the involved anatomy, careful surgical dissection with preservation of the elbow stabilizers, and structured postoperative rehabilitation are paramount to achieve optimal results.
Evidence-based Medicine: Levels of evidence are described in the table of contents. In this article, references 1, 17, 36, and 39 are level III studies. References 9-12, 14, 15, 25, 26, 28, 29-35, 37, 38, and 40-46 are level IV studies.
References printed in bold type are those published within the past 5 years.
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